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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I certify under penalty or law that this document and all attachm nts were
<br />prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information
<br />submitted. Based on mv inquiry of the person or persons who manage the system,
<br />or those persons directly responsible for gathering the information, the information
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<br />I am aware that Ihere are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing violations.
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<br />TELEPHONE
<br />DATE
<br />f772[Q
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<br />(SIGNATURE RINCIPAL EXEfUTIVE
<br />l, OFFICER OR AUTHORIZED AGENT
<br />AREA NUMBER
<br />CODE
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED
<br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Differen()
<br />NAME
<br />ADDRESS 'Cr? r3,y5.„
<br />FACILITY
<br />LOCATION -..
<br />PA Form 3320-1 (Rev. 3/99) Previous editions may be used.
<br />o
<br />t.;.
<br />u(2:
<br />FROM
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM A INPDES)
<br />DISCHARGE MONITORING REPORT (D R) .
<br />PERMIT NUMBER
<br />YEAR
<br />MO
<br />MONITORING PERIOD
<br />DAY
<br />TO
<br />DISCHARGE NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />OTP7: )
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<br />FiTST THWT
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<br />NOTE: Read Instructions before this form.
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />.".s L'7 . s — . c.
<br />Form Approved.
<br />OMB No. 2040-0004
<br />PAGE OF
<br />■CP
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